Venturing into the health care arena when your magazine has Jonathan Cohn to cover the subject is like offering to be a fry cook at Jean Georges. But as someone who did my bit on Obamacare back in the day—I covered the legislative battles for the Washington Post and then co-authored the paper’s insta-book on the law, Landmark—I do want to add my two cents to a frustrating discussion this week among the law’s supporters about whether it was simply too complicated for its boosters—including highly qualified ones like Don Verrilli—to defend.
Reid Cherlin, a former Obama spokesman who is now writing great campaign pieces for GQ, defended Verrilli’s halting performance in court this week by arguing that Obamacare is simply too confusing to defend easily:
It would have been easy for Verrilli—or any of us—to explain single-payer health care. “Look,” we could have said, “the government is paying for everyone to have coverage.” End of story. But single-payer is not what our brilliant, world-leading political system gave us. What it gave us is essentially a halfsy—an extraordinarily confusing patchwork in which some novel legislative mechanisms are used to induce individuals, businesses, insurance companies, and states into doing things that add up to concrete good.
Why did it go down that way? In part because lawmakers are essentially shortsighted, self-serving, and scared of their own shadow. But there's a bigger problem: health care as a system is incredibly complicated, and also incredibly scary and off-putting for voters to think about—which is the reason most people never want to talk about it or learn about it in the first place.
Don’t believe me? Then answer me this: what’s your plan’s deductible for a hospital visit? You don’t know, of course, even though that’s critical information. Let’s try an easier one: what do you pay per month for health coverage? Most people don’t know that, either. All of which makes it extraordinarily hard to communicate about the ACA persuasively or effectively.
Matt Yglesias challenged this assessment, while Kevin Drum came down on Cherlin’s side, writing that, “taken as a whole, Obamacare is really hard to explain to people.” Well, put me down in Yglesias’ camp. One of the things I found most aggravating about covering the endless legislative back and forth over the law was the bipartisan caterwauling about how hard it was to understand. As someone who was spending the better part of those months doing my darndest to explain the law in clear and simple terms, the only way to take such remarks was as a sign that people...weren’t bothering to read what I or many other reporters were writing. I agree wholeheartedly with Cherlin that the health care system as a whole is a labyrinthine mess and that people know precious little about how their care is paid for. But the law’s basic goals and mechanism are really pretty straightforward. It seeks to help the millions of people without health coverage, and the millions more who make do in the over-priced, under-regulated individual insurance market. It seeks to do this—achieving near-universality of coverage—through a three legged-stool approach. 1) Insurers have to offer insurance to anyone who seeks to purchase it, without rejecting them or charging them exorbitant rates because of preexisting conditions. 2) To make this requirement possible, the legislation mandates that almost everyone get coverage—the only way insurers can profitably insure people with preexisting conditions is to get healthy people into the risk pool as well. 3.) To help people observe the mandate, the law expands Medicaid eligibility and, for other people, offers subsidies to make private coverage affordable.
That’s it. Yes, there’s all sorts of other stuff in there as well—insurance regulations and goodies like closing the Medicare drug benefit donut hole and efforts to reform the delivery of care to control costs. But the heart of the law is that three-legged stool, and it is the three-legged stool that is at risk of falling apart if the court decides that one of the most consequential laws in decades can be undone over broccoli-related sophistries.
It’s one thing for the people who want to tear the law down to caricature it as a 2,000-page-plus monstrosity. But those who recognize its benefits ought not to abet that claim. And if they want some help in this regard, they can always read the Post’s book, which, I have to say, did a pretty good job of summarizing the law under a tight deadline. Don’t worry, no self-interest in that pitch—I’m collecting not a cent of royalties.
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